BAitRUW 


AW   IWAUliURAi.  DISSERTATION 
Ufl   LUMBAR  ABSCESS 


M-ftftfaQfr 


£&q 


Columbia  (Bnitier^ftp 

mtijeCttptfltogork 

College  of  ^ijpfiitcianfii  anb  burgeon* 
Xtbrarp 


Digitized  by  the  Internet  Archive 

in  2011  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/inauguraldissertOObarr 


<"YO«^       U  >   >  N  \  V  <V-**\_ 


AM 


INAUGURAL  DISSERTATION 


LUMBAR  ABSCESS. 


SUBMITTED  TO  THE  PUBLIC  EXAMINATION  OF  THE 

FACULTY  OF  PHYSIC 

UNDER  THE  AUTHORITY  OF  THE  TRUSTEES  OF  COLUMBIA  COLLEGE, 
IN  THE  STATE  OF  NEW-YORK, 

The  Right  Rev.  BENJAMIN  MOORE,  D.D.  President] 

FOR  THE  DEGREE  OF 

DOCTOR  OF  PHTSIC, 


BY  WILL 


CITIZEN    OF    THE    STATE    OF    NEW-YORK. 


If  it  be  consonant  with  truth  and  experience  it  matters  not 
from  whom  it  may  differ.  Pott. 


NEW-YORK: 

Printed  by  T.  (2  J.  SWORDS,  Printers  to  the  Faculty  of  Physic 
of  Columbia  College,  .No.  160  Pearl-Street. 

1804. 


/Aff. 


TO 

WRIGHT  POST,  Esq. 

Professor  of  Anatomy  and  Surgery  in  Columbia  College, 

For  his  assiduous  and  generous  Attention  during  the  Author's 
Professional  Studies; 


CHARLES  SMITH,  DANIEL  M'CORMICK, 

AND 

GILBERT  ROBERTSON,  Esquires, 

For  their  Personal  Friendship ; 

THE  FOLLOWING 

DISSERTATION 

Is  respectfully  dedicated. 


INTRODUCTION. 


AMONG  the  many  diseases  to  which  mankind 
are  subject,  there  are,  perhaps,  few  that  have 
proved  more  fatal  in  their  termination  than  that 
of  which  we  are  about  to  speak.  Every  innova- 
tion in  practice  that  may  tend  to  palliate  the  suf- 
ferings, or  prolong  the  life  of  a  fellow  creature, 
may  be  deemed  an  object  of  some  importance. 

From  the  observations  which  I  have  been  able 
to  make  upon  diseases,  my  mind  has  uniformly 
been  impressed  with  the  necessity  of  paying  more 
strict  attention  to  the  state  of  the  solids  of  the 
system  than  is  ordinarily  done;  for  upon  them 
depends  the  state  of  the  fluids. 

I  shall  lay  it  down  as  a  general  position,  that 
diseases  are  produced  by  the  action  of  foreign 
agents  applied  directly  or  indirectly  to  some  part 
of  the  system  capable  of  being  brought  into 
motion,  thereby  producing  an  excitement  greater 
than  natural,  or  by  the  abstraction  of  those  agents 
upon  whose  influence  the  natural  actions  depend. 

Dr.  Cullen,  in  his  First  Lines,  vol.  i.  sect.  43, 
says,  that  a  diminished  action  of  vital  parts  con- 
stitutes atony.  Now,  where  the  ordinary  actions 
of  the  system  are  lessened  there  cannot  be  such 
an  expenditure  of  excitability;  consequently  the 


6  On  Lumbar  Abscess. 

capability  of  the  system  to  be  operated  upon  is 
increased:  hence  I  conclude  that  the  atony  of 
Dr.  Cullen  and  the  direct  debility  of  Dr.  Brown 
are  synonymous.  That  excitability  is  accumu- 
lated by  the  abstraction  of  stimuli,  I  think  is 
proved  from  what  takes  place  in  several  diseases. 
In  Cholera  the  great  prostration  of  strength 
that  is  produced  by  the  sudden  evacuation  of  the 
contents  of  the  stomach  and  intestines  render  the 
system  so  highly  susceptible,  that  spasm  and  con- 
vulsion are  its  common  attendants.  The  predis- 
position to  Puerperal  Fever,  occasioned  by  the 
expulsion  of  the  contents  of  the  impregnated 
uterus,  goes  far  to  prove  this  fact.  In  this  dis- 
ease, not  only  inflammation  of  the  uterus  is  pro- 
duced, attended  with  general  febrile  irritation, 
but  frequently  the  inflammation  is  extended  to 
all  the  abdominal  viscera;  the  pressure  which 
had  uniformly  sustained  and  supported  them  dur- 
ing the  term  of  gestation  being  withdrawn.  The 
evacuation  of  the  water  of  Ascites  often  produces 
a  sudden  derangement  of  the  system,  and  fre- 
quently lays  the  foundation  for  peritoneal  inflam- 
mation, unless  the  abdomen  is  equally  supported 
by  bandage.  The  spontaneous  bursting  of  the 
tumour  formed  at  the  sacrum  in  the  disease  called 
Spina  Bifida,  occasions  such  sensibility  of  the 
parts  affected,  as  to  produce  inflammation,  which 
generally  terminates  in  death. 

In  all  those  cases  the  cause  is  no  doubt  a  sub- 
duction  of  stimuli ;  but  they  are  mechanical  sti- 


On  Lumbar  Abscess.  7 

muli,  arising  from  support  and  distention,  and 
though  extraneous  to  the  system,  yet  they  have 
become  habitual  by  their  continuance. 

Upon  these  principles  I  shall  endeavour  to 
prove,  in  the  prosecution  of  this  Dissertation, 
that  the  vitiated  secretion  and  febrile  commotion 
attendant  upon  Psoas  Abscess  chiefly,  if  not 
solely,  depend  upon  the  sudden  and  entire  eva- 
cuation of  the  contained  matter. 


HISTORY  OF  LUMBAR  ABSCESS. 

THIS  disease  has  derived  its  name  from  its 
situation,  which  is  generally  in  the  lumbar  re- 
gion, though  it  sometimes  originates  near  the 
sacrum,  in  the  cavity  of  the  pelvis;  under  which 

circumstance  this  epithet  is  improperly  applied. 
It  has  likewise  been  designated  by  the  term 
Psoas  Abscess,  when  it  originates  in  the  cellular 
substance  near  the  psoas  muscle,  and  in  the  su- 
perior parts  of  the  pelvis,  which  is  its  most  com- 
mon seat.  Persons  of  a  scrophulous  habit  are 
more  peculiarly  subjected  to  its  attacks,  though 
its  existence  may  frequently  be  traced  as  the 
effects  of  external  violence  on  the  part.  The 
symptoms  which  denote  its  presence  are  pain 
and  uneasiness  about  the  loins.  These  are  in- 
creased by  particular  motions  of  the  lower  ex- 
tremities, such  as  rolling  the  thigh  and  turning 


8  On  Lumbar  Abscess. 

the  toes  outward :  but  so  little  is  the  inconveni- 
ence with  which  it  is  sometimes  attended,  that 
the  pointing  of  the  matter  in  some  distant  part 
is  the  first  sure  indication  of  the  disease. 

The  inflammation  being  slight,  is  insufficient 
to  produce  adhesions  in  the  surrounding  parts, 
by  which  the  matter  might  be  confined:  hence 
it  descends  by  its  own  gravity  through  the  cellu- 
lar substance,  and  shows  itself  in  different  situa- 
tions, remote  from  its  origin.  The  pus  thus 
formed  is  generally  deposited  either  on  the  inter- 
nal part  of  the  thigh,  or  near  the  rectum,  or  in 
the  loins,  or,  as  most  frequently  happens,  in  the 
course  of  the  vessels  running  under  Poupart's 
ligament.  The  integuments  retain  their  natural 
appearance:  the  tumour  is  unaccompanied  with 
pain,  and  may  be  handled  without  the  least  in- 
convenience, or  producing  pain  and  uneasiness 
to  the  patient;  and,  by  placing  him  in  a  horizon- 
tal position,  the  matter  may,  by  pressure,  fre- 
quently be  forced  into  the  cavity  of  the  abdomen; 
it  likewise  receives  an  evident  impulse  during  the 
paroxysms  of  coughing.  The  disease  being  thus 
formed,  as  the  only  mean  of  producing  relief, 
the  pus  is  to  be  evacuated,  which,  on  the  first 
discharge,  is,  in  general,  perfectly  bland  and  in- 
odorous. This,  however,  is  succeeded  by  an 
icterous  and  extremely  foetid  matter,  accompa- 
nied with  a  symptomatic  fever,  which  seldom 
fails  to  terminate  the  sufferings  of  the  patient  by 
lingering  death. 


On  Lumbar  Abscess.  9 

I  shall  now  proceed  to  investigate  the  cause  of 
that  particular  derangement  which  succeeds  the 
ordinary  evacuation  of  the  matter  in  Lumbar 
Abscess;  conceiving  that,  should  this  be  ascer- 
tained, the  indication  of  cure  would  naturally- 
present  itself.  As  the  constitutional  derangement 
corresponds  with  the  topical  affection,  our  first 
inquiry  will  be — 

To  what  cause  may  we  attribute  the  local  in- 
flammation subsequent  to  the  discharge  of  the 
matter?  And,  2dly.  How  far  does  this  tend  to 
the  production  of  that  febrile  commotion  and 
vitiated  secretion  which  generally  succeed  such 
evacuations? 

The  admission  of  air  into  the  cavity  of  the  abscess, 
after  the  evacuation  of  the  pus,  was  formerly  sup- 
posed to  be  the  cause  of  all  the  mischievous  effects 
which  followed.  These  it  was  thought  to  induce, 
1st.  By  excessively  stimulating  the  cyst,  and 
thereby  producing  inflammation;  and,  2dly.  By 
promoting  the  putrefaction  of  the  contained  pus, 
to  the  absorption  of  which  (in  a  state  of  putridity) 
the  constitutional  derangement  which  succeeded 
was  attributed.  Let  us  examine  these  opinions, 
and  see  how  far  they  are  supported  by  facts. 

We  daily  see  air  applied  to  large  excoriated 
surfaces,  as  well  as  to  ulcers  in  different  parts  of 
the  body,  without  producing  any  extraordinary 
inflammation,  or  sensibly  changing  the  state  of 
the  matter  secreted.  But  to  this  it  may  be  ol> 
jected,  that  there  is  a  difference  between  the  sur* 

2 


JO  On  Lumbar  Abscess. 

faces  of  those  parts  of  the  body  which  are  con- 
tinually exposed  to  the  contact  of  air,  and  of 
those  cavities  which,  from  their  natural  situa- 
tion, are  more  peculiarly  exempted  from  its  in- 
fluence. To  this  I  answer,  that  the  admission 
of  air  into  the  cellular  substance  in  Emphysema 
is  a  case  perfectly  in  point.  This  is  a  secreting 
membrane,  in  every  respect  similar  to  that  which 
is  the  seat  of  Psoas  Abscess ;  and  yet  we  find  that 
air  has  in  this  way  not  only  been  admitted,  but 
even  in  such  quantities  as  to  produce  a  disten- 
tion of  the  whole  body,  without  being  attended 
by  the  least  inflammation  whatever.  The  ex- 
periments of  Mr.  Ashley  Cooper,  as  related  by 
Mr.  Abernethy,  likewise  prove  that  those  dele- 
terious effects  w_hich  have  been  attributed  to  air, 
when  allowed  to  come  in  contact  with  ulcerated, 
surfaces  and  secreting  membranes,  are  not  attri- 
butable to  that  agent. 

In  order  to  determine  this  fact,  he  inflated 
the  abdomen,  thorax,  and  cellular  substance  of 
different  dogs,  and  carefully  closed  the  aperture 
through  which  the  air  was  impelled.  The  con- 
sequence was,  that  the  air  was  absorbed  from 
the  cavities,  the  wounds  healed  by  the  first  in- 
tention, and  little  or  no  inflammation  was  ex- 
cited. But  even  admitting  that  a  certain  part 
of  atmospheric  air,  viz.  its  oxygen,  is  capable 
of  stimulating  the  living  solids  of  an  animal  body, 
and  that  a  proportion  of  air  is  admitted  into  the 
cavity  of  an  abscess  after  an  evacuation  of  the 


On  Lumbar  Abscess.  1 1 

matter,  still  this  would  not  contain  but  little 
more  than  one  fourth  part  of  oxygen,  which  is 
the  only  ingredient  possessed  of  stimulating  pro- 
perties; but  it  must  be  likewise  remembered  that 
even  this  is  confined  in  the  cavity,  and  perfectly 
at  rest :  hence  there  can  be  no  new  accession  of 
air,  and  the  small  quantity  of  oxygen  then  within 
the  cyst  is  quickly  absorbed  by  the  effused  fluids. 
As  to  the  azotic  portion  which  remains,  experi- 
ments have  sufficiently  proved  that  it  may  be 
applied  to  ulcerated  surfaces  with  perfect  im- 
punity. 

From  these  facts  combined,  I  conceive  that 
I  am  authorised  to  conclude  that  the  admission 
of  air  into  the  cavity  of  a  Lumbar  Abscess  is 
not  the  cause  of  that  peculiar  derangement  of 
the  part  which  succeeds  an  evacuation  of  the 
matter.  I  shall  endeavour  to  show,  from  a  va- 
riety of  circumstances,  that  this  principally,  if 
not  entirely,  depends  upon  that  collapsed  and  un- 
supported state  of  the  parts  which  necessarily 
arises  from  a  complete  and  entire  discharge  of 
the  pus.  It  has  been  laid  down  as  a  law  of  the 
animal  economy,  that  when  a  portion  of  usual 
or  accustomed  stimuli  is  suddenly  subducted 
from  a  part  or  the  whole  of  the  system,  there 
excitability  is  generated  or  increased;  and  that 
the  part  becomes  susceptible  of  impressions  in 
proportion  to  the  subduction.  Now,  the  matter 
of  Lumbar  Abscess  must  be  considered  as  a  sti- 
mulus, since  not  only  as  it  respects  the  system  it 


12  On  Lumbar  Abscess. 

is  evidently  extraneous,  but  likewise  as  it  dis- 
tends and  supports  the  surrounding  parts:  hence, 
when  this  stimulus  of  distention  is  suddenly  with- 
drawn by  an  evacuation  of  the  matter,  direct  de- 
bility must  necessarily  succeed;  in  consequence 
of  which  the  parts  become  preternaturally  sen- 
sible to  the  application  of  other  stimuli.  In  this 
way  I  can  readily  suppose  that  a  stimulus,  whe- 
ther produced  by  the  wound  which  is  made  to 
evacuate  the  matter,  or  in  any  other  way,  may, 
upon  this  accumulated  excitability,  produce  con- 
siderable inflammation.  But  if  the  parts  were 
not  rendered  preternaturally  sensible,  why  should 
a  wound  inflicted  in  them  produce  such  violent 
effects,  since  the  point  in  which  it  is  made  can- 
not be  considered  as  involved  in  the  original  dis- 
ease, but  merely  as  the  receptacle  of  matter 
formed  at  a  distance?  Hence  no  symptoms  of 
inflammation  appear  until  deprived  of  their  usual 
support,  by  a  complete  evacuation  of  the  matter. 
This  then  I  presume  to  be  the  cause  of  that  local 
inflammation  which  generally  succeeds  the  ope- 
ration. 

We  shall  next  consider  the  cause  of  the  viti- 
ated state  of  the  secretion,  and  shall  endeavour 
to  ascertain  how  far  it  may  depend  upon  the 
debility  which  is  induced,  and  the  topical  inflam- 
mation which  is  consequent  upon  the  collapsed 
state  of  the  cyst.  I  assume  it  as  a  fact,  and  I 
am  warranted  by  general  opinion,  that  pus  is 
the  effect  of  an  altered  secretion:  if  so,  it  must 


On  Lumbar  Abscess.  1 3 

depend  upon  a  particular  state  of  the  vessels. 
"Whenever  great  debility  prevails  in  the  system 
generally,  or  in  a  gland  locally,  the  secreted  fluid 
loses  its  natural  appearance,  and  is  discharged 
from  the  vessels  in  a  crude  and  undigested  state, 
owing  to  their  not  being  able  to  perform  their 
usual  functions.  This  frequently  happens  in  the 
stomach,  liver,  and  other  glands,  in  cases  of 
great  debility,  and  is  more  particularly  exempli- 
fied in  the  instance  of  ordinary  ulcers  which  are 
situated  upon  the  extremities  of  those  who  are  of 
an  enfeebled  habit  of  body.  Every  person  con- 
versant with  surgery  must  often  have  observed 
that  these  will  at  first  appear  well-conditioned, 
the  granulations  of  a  good  healthy  colour  and 
firm,  the  pus  perfectly  bland  and  of  a  proper 
consistence;  but  in  a  short  time  an  obvious 
change  takes  place,  the  granulations  become 
full  and  assume  a  fungous  appearance,  the  secre- 
tion becomes  thin,  ichorous,  and  extremely  fetid. 
To  prove  that  this  arises  from  debility  of  the 
part,  we  need  only  advert  to  the  method  of  cure, 
that  is,  tight  bandaging,  which  is  alone  fre- 
quently sufficient  to  alter  the  appearance  of  the 
ulcer;  but  if  aided  with  bark,  wine,  and  a  ge- 
nerous diet,  the  parts  may  soon  be  completely 
restored  to  a  healthy  state.  All  plasters  that 
are  used  in  the  form  of  bandage,  and  all  stimu- 
lant ointments,  generally  called  digestives,  act 
upon  the  same  principle. 

The  fever  attendant  upon  this  disease  has  been 


14  On  Lumbar  Abscess. 

attributed  to  an  absorption  of  the  matter  con- 
tained within  the  sack,  and  to  its  being  conveyed 
into  the  circulating  vessels.  We  shall  first  in- 
quire how  far  this  cause  is  capable  of  producing 
the  effect. 

Mr.  John  Hunter  says,  fc  We  may  remark,  that 
in  large  abscesses  that  have  not  been  preceded 
by  inflammation,  the  hectic  disposition  seldom  or 
never  comes  on  till  after  they  are  opened."*  If 
this  be  fact,  as  it  most  undoubtedly  is,  ought 
not  absorption  to  be  greatest  whilst  pressure  is 
greatest?  It  is  a  law  of  the  animal  economy,  that 
pressure  produces  absorption;  and  yet  we  find 
that,  under  the  most  favourable  circumstances  for 
the  absorption  of  this  matter,  no  ferver  arises. 
Dr.  Reid,  in  his  Essay  on  Phthisis  Pulmonalis, 
observes,  "  If  absorption  was  really  the  cause  of 
hectic  fever,  it  would  be  present  always,  and  in 
every  case  where  matter  was  present,  or  real  pus 
spit  up  from  the  lungs  ;"f  yet  daily  experience 
proves  the  contrary.  Can  it  be  supposed,  on  the 
other  hand,  that,  after  the  evacuation  of  the  mat- 
ter, absorption  takes  place  and  fever  is  produced? 
This  appears  to  me  equally  inconsistent;  for  after 
the  cyst  is  deprived  of  its  support,  the  parts  be- 
come extremely  debilitated,  the  absorbents  in 
common  with  every  other  part;  and  this  debility 
is  obvious  by  the  thinness  of  the  discharge,  it 
merely  being  poured  out  from  the  extremities  of 

*  Vide  Hunter  on  the  Blood,  vol.  ii.  p.  224.         f  vide  Reid>  P-  86- 


On  Lumbar  Abscess.  1 5 

the  relaxed  and  enfeebled  vessels,  and  is  not  a 
perfect  secretion.  But  if  we  admit  that  the  mat- 
ter may  be  absorbed,  is  it  possible  that  it  can 
have  such  powerful  effects  upon  the  system? 
Mr.  Hunter,  in  speaking  on  this  subject,  pro- 
proses  this  question:  "  If  absorption  of  matter 
produces  such  violent  effects  as  are  commonly 
ascribed  to  it,  why  does  not  venereal  matter  do 
the  same?"*  and  yet  we  find  buboes  of  consi- 
derable size,  which  are  just  ready  to  break,  ab- 
sorbed and  taken  away  in  a  few  days,  and  no 
fever  excited.  Certainly  if  the  absorption  of 
ordinary  pus  could  produce  fever,  that  of  a  spe- 
cific matter  ought  to  do  the  same, 

"  When  matters  of  an  injurious  nature  are 
taken  into  the  system  by  absorption,  the  absor- 
bents are  first  inflamed,  the  lymphatic  glands 
conjested,  and  the  poison  arrested.  If  this  pro- 
duce fever,  it  is  not  hectic,  but  of  a  more  violent 
and  active  kind."-)" 

"  We  likewise  find  very  large  collections  of 
matter  which  have  been  produced  without  visible 
inflammation,  such  as  many  of  the  scrofulous 
kind,  and  which  are  wholly  absorbed,  even  in  a 
very  short  time,  yet  no  bad  s)mptoms  follow."J 

I  conclude  this  part  of  the  subject  with  saying, 
that  if  hectic  fever  depended  upon  the  absorp- 
tion of  matter,  no  patient  ought  to  recover  of  this 

*  Hunter  on  the  Blood,  vol.  ii.  p.  223. 

f  Vide  Abernethy's  Surgical  and  Physical  Essays. 

J  Hunter  on  the  Blood,  vol.  ii.  p.  223. 


16  On  Lumbar  Abscess. 

disease  until  suppuration  had  ceased ;  but  this  we 
know  to  be  contrary  to  truth.  From  this  collec- 
tion of  evidence  I  infer,  that  the  fever  induced 
in  this  disease  is  not  owing  to  the  absorption  of 
matter,  but  to  some  other  cause. 

An  author,  in  speaking  of  Psoas  Abscess,  ob- 
serves, "  A  symptomatic  fever  generally  attends 
this  complaint,  and  closes  the  scene.  But  what 
is  very  remarkable,  this  fever  does  not  come  on 
during  the  time  the  matter  is  confined,  nor  to 
any  degree  for  forty-eight  hours  after  the  matter 
is  let  out.  This  circumstance  is  extraordinary, 
as  it  cannot  arise  from  the  absorption  of  matter, 
for  that  must  have  been  greater  before  the  open- 
ing; nor  from  a  wasting  in  consequence  of  the 
evacuation  of  the  matter,  as  that  was  before  ex- 
travasated,  and  was  extraneous  with  respect  to 
the  constitution;  nor  from  the  admission  of  air, 
for  that  in  other  cases  does  not  produce  such 
effects :  we  are  therefore  at  a  loss  to  know  why 
the  symptomatic  fever  does  not  occur  till  after 
the  discharge  of  the  matter."*  To  answer  this 
query  shall  be  my  next  inquiry. 

We  have  endeavoured  to  prove  that  the  ab- 
sorption of  pus  is  inadequate  to  the  production 
of  the  disease:  we  shall  see  how  far  it  may  de- 
pend upon  the  irritation  caused  by  the  local  in- 
flammation induced  upon  the  surface  of  the  cyst. 
The  cause  of  the  local  inflammation  has  been 

*  Motherby's  Dictionary, 


On  Lumbar  Ab$ces$<  17 

already  investigated,  and  has  been  proved  to  de- 
pend upon  the  collapsed  state  of  the  parts  from 
the  sudden  subduction  of  the  contained  matter, 
thereby  producing  a  preternatural  degree  of  ex- 
citability in  the  parts  to  be  operated  upon  by  any 
stimulus  applied.  "  In  some  cases,"  says  Mn 
Hunter,  "  as  in  Lumbar  Abscess,  the  extent  of 
surface  to  inflame  is  immense,  in  comparison  to 
the  original  disease,  and  of  course  when  such 
abscesses  do  inflame,  the  symptoms  in  the  con- 
stitution are  in  the  same  proportion."* 

From  these  data  the  subject  is  fully  explicable: 
here  is  an  extensive  surface  rendered  preternatu* 
rally  sensible,  inflammation  suddenly  takes  place, 
and  the  constitution  is  rendered  susceptible  of 
the  impressions  by  the  sympathetic  association  of 
parts.  That  the  symptomatic  fever  must  depend 
upon  the  previous  local  inflammation  induced, 
and  this  inflammation  upon  the  direct  debility 
attendant  upon  the  collapsed  state  of  the  cyst, 
we  shall  endeavour  to  prove  from  the  following 
cases: 

"  I  have  seen  large  Lumbar  Abscesses  open 
of  themselves  on  the  lower  part  of  the  loins, 
which  have  discharged  a  considerable  quantity 
of  matter,  then  close  up,  then  break  out  ane w> 
and  so  on  for  months,  without  giving  any  other 
disturbance;  but  when  opened,  so  as  to  give  a 
free  discharge  to  the  matter,  inflammation  has 

*  Vide  Hunter  on  the  Blood,  vol.  ii.  p.  113- 

3 


18  On  Lumbar  Absceso. 

immediately  succeeded,  fever  has  come  on,  and, 
from  the  situation  of  the  parts  inflamed,  as  well 
as  their  extent,  death  in  a  very  few  days  after 
has  been  the  consequence."*  These  are  full  in 
point.  While  the  cyst  retained  support  enough 
to  keep  up  a  proper  degree  of  excitement,  no 
unusual  degree  of  excitability  could  be  produced; 
and  as  no  unusual  stimulus  was  applied,  no  in- 
flammation could  be  excited:  but  when  the  mat- 
ter was  completely  evacuated  by  an  artificial 
opening,  the  parts  were  rendered  susceptible  by 
the  abstraction  of  the  stimulus  of  support;  the 
irritation  of  the  wound,  and  the  excitability  of 
the  parts  being  increased,  inflammation  takes 
place,  and,  consequently,  a  general  affection  of 
the  system  by  consent  of  parts. 

It  may  be  asked,  if  the  fever  accompanying 
this  disease  depends  upon  local  irritability,  and 
not  upon  the  absorption  of  the  matter,  why  does 
not  the  irritation  attending  the  amputation  of  a 
limb,  or  the  inflammation  of  the  pleura,  &c. 
produce  a  fever  of  the  same  type  with  that  of 
hectic,  accompanied  with  exacerbations  and 
remissions?  The  reason,  I  think,  is  obvious. 
Where  a  part  of  the  body  has  acquired  a  preter- 
natural sensibility,  by  the  loss  of  the  stimulus  of 
support,  distention,  and  habit,  the  common  and 
ordinary  stimuli  of  life  shall  operate  upon  it  with 
increased  violence:  here  is  not  a  direct  applica- 

f  Vide  Hunter,  vol,  ii.  p.  119. 


On  Lumbar  Abscess.  19 

tion  of  stimulant  power,  so  as  to  produce  a  sud- 
den and  permanent  action,  which  shall  continue 
the  same  as  it  was  when  first  induced,  without 
intermission,  until  the  parts  are  no  longer  capa- 
ble of  supporting  that  action,  and  they  fall  into 
a  state  of  indirect  debility;  but  a  part  rendered 
preternaturally  sensible  by  a  peculiar  cause,  that 
shall  be  operated  upon  at  different  times  by  the 
common  stimuli  of  life,  and  as  often  as  they  are 
applied,  so  often  wTill  a  paroxysm  be  produced. 
Dr.  Darwin,  in  his  Zoonomia,  says,  "  If  the 
degree  of  quiescence  occasioned  by  the  defect  of 
stimulus  be  very  great,  it  will  recur  a  second 
time  by  a  slighter  cause  than  that  which  first  in- 
duced it.  If  the  cause  which  first  induced  the 
second  fit  recurs  the  succeeding  day,  the  quoti- 
dian fever  is  produced ;  if  not  till  the  alternate 
day,  the  tertian  fever,"  &c. 

Hectic  fever  is  attended  throughout  with  a 
morbid  frequency  of  pulse,  with  exacerbations 
at  evening,  and  remissions  in  the  morning.  Now, 
the  continued  frequency  of  pulse  depends  upon 
the  uniform  local  irritation,  the  evening  exacer- 
bation upon  the  excitability  of  the  system  gene- 
rated during  the  morning  remission,  brought  into 
action  by  the  stimulus  of  food,  heat,  light,  and 
sound,  with  all  the  ordinary  excitants  of  life 
that  have  their  action  during  the  day:  thus, 
when  the  fever  is  first  induced  by  the  local  affec- 
tion, the  force  with  which  the  excitants  were 
applied  being  but  slight,  the  paroxysm  of  conse- 


20  On  Lumbar  Abscess. 

quence  must  be  of  short  duration.  The  produc- 
tion of  the  second  paroxysm  must  depend  upon 
the  excitability  accumulated  during  the  remission 
and  the  effect  of  stimuli  during  the  day:  hence 
we  have  at  evening  an  increase  of  action,  and 
in  the  morning  a  remission  of  the  symptoms. 

From  the  observations  already  made,  the  me- 
thod of  prevention  and  cure  of  this  disease  more 
readily  present  themselves.  In  its  incipient  stage, 
when  it  is  confined  to  the  loins,  and  before  mat- 
ter is  formed,  certain  symptoms  obtain,  that,  to  a 
person  conversant  with  the  disease,  would  give 
the  strongest  probability  of  its  commencement, 
such  as  pain  in  the  loins,  accompanied  with  a 
difficulty  of  moving  the  thigh,  taking  place  in 
persons  who  are  of  delicate  health  or  of  a  scro- 
fulous disposition :  but  these  symptoms  being 
common  to  many  ordinary  complaints,  make  us 
too  inattentive  to  such  circumstances  -,  whereas, 
if  the  disease  was  taken  in  its  forming  stage,  all 
those  dreadful  symptoms  which  are  generally  the 
consequence  might  be  prevented  by  early  atten- 
tion. Surgeons  of  the  greatest  respectability 
agree  as  to  the  mode  of  treating  this  disease  in 
its  commencement.  The  means  are  general  and 
local.  The  general  are  those  that  may  tend  to 
relieve  congestion;  such  as  evacuations  from  the 
system  (if  the  disease  should  be  occasioned  by 
local  injury),  by  the  lancet,  by  the  bowels,  and 
by  the  skin.  The  local  comprehend  scarifica- 
tions, blisters,  setons,  &c.  to  the  loins,  perfect 


On  Lumbar  Abscess.  21 

rest,  with  a  strict  confinement  to  bed,  as  mo- 
tion of  the  lower  extremities  certainly  tends  to 
aggravate  the  symptoms,  by  bringing  into  action 
the  psoas  muscle,  with  those  contiguous.  If 
these  remedies  are  used,  the  patient  has  every 
probability  of  recovering  without  farther  disease. 
But  as  it  frequently  happens  that  the  pointing  of 
the  matter  in  some  distant  part  is  the  first  symp- 
tom that  presents  itself,  we  are  now  to  consider 
the  mode  of  relief  best  adapted  to  this  stage  of 
the  disease.  As  at  this  time  there  is  no  general 
affection  of  the  system,  and  the  patient  is  in  or- 
dinary health,  our  attention  is  first  led  to  the  re- 
moval of  the  matter  confined  within  the  cyst. 
Different  Surgeons  have  recommended  different 
modes  of  evacuating  this  matter.  Mr.  Bell  pre- 
fers the  introduction  of  a  trocar  when  the  case 
is  obvious;  but,  as  this  disease  may  be  confounded 
with  others,  he  thinks  a  scalpel  should  be  used, 
cutting  down  carefully,  as  in  hernia,  until  the 
matter  flows. 

Mr.  Ford,  in  his  Observations  on  the  Disease 
of  the  Hip-Joint,  seems  clearly  of  opinion  that 
abscesses  should  be  left  to  themselves  to  burst 
spontaneously,  and  the  matter  evacuated  in  that 
way.  Mr.  Abernethy  recommends  discharging 
the  pus  by  introducing  a  lancet  through  the  inte- 
guments, then  passing  it  for  a  small  distance  be- 
tween the  skin  and  fascia,  and  then  by  depres- 
sing the  point  of  the  lancet  to  puncture  the  cyst. 
The  advantages  accruing  from  a  small  opening, 


2  2  On  Lumbar  Abscess. 

and  that  made  with  a  keen  cutting  instrument, 
are,  the  matter  is  evacuated,  and  as  little  vio- 
lence done  to  the  parts  as  possible,  so  that  inflam- 
mation might  not  be  induced.  But,  unfortunately 
for  us,  the  practices  hitherto  pursued  for  the 
evacuation  of  the  matter  have  generally  been  un- 
successful: some  few  solitary  cases  have  occured 
in  which  the  patients  have  recovered  without 
much  suffering,  but  the  majority  have  fallen  a 
sacrifice  to  the  symptoms  that  have  succeeded 
the  operation. 

The  method  of  opening  the  cyst,  recommended 
by  Mr.  Abernethy,  is,  in  my  opinion,  the  most 
preferable,  and  his  reasoning  upon  the  subject 
most  valuable.  But,  with  all  due  deference  to 
the  opinions  of  men  so  deservedly  eminent,  I 
beg  leave  to  propose  to  the  consideration  of  the 
gentlemen  of  the  faculty,  a  mode  of  operating 
which  is  the  result  of  my  reflections  upon  the 
nature  and  progress  of  the  disease. 

After  having  ascertained  the  existence  of  the 
disease,  so  as  to  warrant  an  operation,  I  would 
recommend  that  the  incision  made  for  the  dis- 
charge of  the  matter  be  by  a  lancet  passed  in  a 
longitudinal  direction  as  respects  the  thigh,  ob- 
liquely through  the  integuments  and  fascia  in  the 
lowermost  part  of  the  tumour.  The  incision 
thus  made  is  to  be  small,  and  about  one-fourth 
of  the  matter  evacuated;  the  orifice  is  then  to 
be  closed,  and  a  piece  of  adhesive  plaster  (the 
least  stimulating)  applied  over  the  wound,  and 


On  Lumbar  Abscess:.  23 

a  broad  flannel  uniting  bandage  over  that  and 
the  most  depending  part  of  the  tumour,  endea- 
vouring to  press  the  matter  upwards,  so  that  the 
wound  may  have  every  advantage  of  uniting  by 
the  first  intention.  The  patient  is  to  be  kept  in 
bed,  in  an  horizontal  position,  avoiding  every 
thing  that  may  tend  to  stimulate  or  bring  on 
excitement;  such  as, light,  heat,  sound,  and  sti- 
mulating food.  If  the  wound  should  unite  and 
heal  soundly,  it  would  be  most  advisable  to 
puncture  the  cyst  in  another  place,  to  make  the 
next  evacuation,  which  should  be  in  the  course 
of  three  or  four  days  after  the  first,  and  by  the 
same  means  let  out  about  one-fourth  of  the 
quantity  remaining  in  the  cyst,  and  so  to  continue 
the  evacuation  gradatim  until  the  cyst  is  com- 
pletely emptied. 

The  advantages  of  this  mode  of  treating  the 
disease,  I  think,  must  be  obvious  to  every  person 
conversant  with  the  laws  of  the  animal  economy. 
By  partially  subducting  the  matter,  the  quantity 
remaining  in  the  sac,  in  conjunction  with  the 
elasticity  of  the  cellular  substance,  is  equal  to 
the  support  of  the  parts  concerned.  When  the 
pressure  is  taken  off  the  cellular  substance  reacts, 
and  the  muscular  fibres  of  the  surrounding  parts 
contract,  so  as  to  adapt  themselves  to  the  quan- 
tity they  contain.  In  this  way  collapse  is  pre- 
vented, and  no  excitability  accumulated;  conse- 
quently no  inflammation  obtains,  and  the  matter, 
when  let  out  at  the  second  operation,  retains  its 


24  On  Lumbar  Abscess. 

healthy  appearance.  As  no  local  inflammation 
is  present,  there  is  little  or  no  cause  for  general 
febrile  affection;  the  patient,  therefore,  remains 
unaffected,  or  if  affected,  the  fever  is  very  slight, 
and  the  system  soon  becomes  equalized;  there 
is  no  wasting  of  strength  from  excessive  excite- 
ment; the  remedies  given  to  support  the  patient 
cannot  act  with  violence,  as  the  parts  are  not 
rendered  preternatural ly  sensible  by  a  sudden 
loss  of  support,  and  the  time  allowed  between 
every  evacuation  gives  opportunity  to  the  parts 
to  gain  their  wonted  tone.  To  prove  what  I 
have  said  takes  place  under  such  circumstances, 
I  shall  relate  a  case  recorded  by  Mr.  Abernethy 
in  his  Treatise  on  Lumbar  Abscess : — ■ 

"  Elizabeth  Ridley,  aged  fifty-five,  had,  for 
one  year  and  a  half  before  her  admission  into  the 
hospital,  suffered  much  from  bad  health;  she 
then  had  a  severe  cough,  accompanied  with  much 
fever.  About  ten  months  ago  she  had  a  very 
acute  pain  in  her  loins,  which  abated,  in  some 
degree,  ten  weeks  after  its  first  attack;  at  that 
time  she  observed  a  tumour  in  her  groin,  which 
had  gradually  increased  in  size.  The  pain  had 
been  continued,  though  at  intervals  it  suffered 
considerable  abatement:  the  veins  on  the  fore 
part  of  the  thigh  had  become  varicous,  and  the 
leg  cedematous.  The  tumour  was  of  a  circular 
form,  about  four  inches  in  diameter.  It  had 
much  protruded  the  fascia,  and  matter  was  vio- 
lently impelled  into  it  on  coughing.     She  now 


On  Lumbar  Abscess.  25 

complained  of  occasional  pain  of  her  stomach, 
of  failure  of  appetite,  and  a  costive  state  of  her 
bowels;  her  pulse  was  slow  and  feeble,  her  tongue 
pale,  and  her  health  considerably  beneath  the  na- 
tural standard. 

"  On  the  8th  of  November  I  punctured  the 
lower  part  of  the  tumour  with  a  lancet,  carrying 
it  obliquely  about  half  an  inch  between  the  skin 
and  the  fascia,  and  discharged  eleven  ounces  of 
good  pus,  but  did  not  empty  the  abscess.  The 
orifice  of  the  skin  and  cyst  did  not  then  corres- 
pond, and  on  coughing  there  was  still  perceived  a 
considerable  impulse  of  matter  from  the  cavity  in 
the  loins. — I  was  unwilling  to  irritate  the  cyst  by 
the  introduction  of  any  instrument  to  separate  the 
lips  of  the  wound,  therefore  I  closed  the  orifice 
with  sticking  plaster,  and  every  thing  remained 
quiet  till  the  third  day,  when,  by  a  fit  of  coughing, 
the  orifice  was  burst  open,  and  matter  oozed  from 
beneath  the  plaster.  If  I  suffered  it  to  remain 
open,  my  original  plan  of  treatment  would  be 
frustrated;  I  therefore  resolved  to  let  out  the 
collected  matter,  least  distention  of  the  fascia 
and  integuments  should  prevent  the  wound  from 
healing.  I  again  introduced  the  lancet  through 
the  same  orifice,  and  wounded  it  so  as  to  make 
it  bleed,  and  gave  a  discharge  to  five  ounces  of 
pus;  the  abscess  though  did  not  even  now  ap- 
pear to  be  completely  emptied.  I  preferred  to 
introduce  the  lancet  through  the  same  orifice 
rather  than  make  another  opening,  that  this  new 

4 


26  On  Lumbar  Abscess. 

injury  might  excite  in  the  divided  parts  a  new- 
disposition  to  unite.  If  I  bad  not  again  made 
the  separated  parts  bleed,  they  probably  would 
have  united  by  granulations;  their  surfaces  would 
have  been  for  some  time  kept  separate  by  a  puru- 
lent secretion,  and  air  would  have  been  admitted 
into  the  cavity  of  the  abscess:  but  the  effused 
blood  glued  together  these  edges,  and  thus  ob- 
structed the  aperture  till  its  organization  made 
the  reunion  perfect. 

"  The  woman  suffered  no  evident  alteration  in 
her  health,  but  became  much  easier  with  respect 
to  her  loins.  The  varicose  veins  and  the  oedema 
of  the  leg  now  no  longer  appeared.  These  symp- 
toms, doubtless,  originated  from  the  pressure  of 
her  loins,  occasioned  by  matter,  of  which  it  was 
very  evident  there  was  a  large  collection. 

"  On  the  18th  the  tumour  was  again  punc- 
tured, and  eight  ounces  of  fluid  evacuated.  The 
matter  before  had  been  incompletely  discharged; 
now  I  believe  the  tumour  was  entirely  emptied. 
This  last  discharged  matter  was  perfectly  inodor 
rous,  and  the  thigh  uninflamed.  I  made  this 
aperture,  at  the  side  of  the  tumour,  with  the  edges 
of  the  lancet  held  upwards  and  downwards,  and 
not  transversely,  as  the  former  openings  had  been 
made.  This  I  did  that  the  efforts  employed  in 
coughing  might  have  less  effect  in  impelling  the 
matter  through  the  orifice,  which  soon  healed. 

"  In  the  following  week  she  complained  that 
she  was  restless  and  could  not  sleep,  neither  had 


On  Lumbar  Abscess.  27 

she  her  usual  degree  of  appetite;  her  pulse,  how- 
ever, was  not  quickened,  nor  did  any  other  signs 
of  constitutional  indisposition  appear.  No  matter 
was  now  collected  beneath  the  fascia,  and  after 
waiting  another  week  without  any  apparent  col- 
lection being  made,  on  the  25th  of  November  I 
introduced  a  lancet  through  the  fascia  of  the 
thigh,  with  a  design  to  admit  the  air  into  the 
cavity  of  the  abscess  that  remained.  I  did  not 
perceive  any  matter  issue  from  the  opening.  As 
the  integuments  covering  the  fascia  were  thicken- 
ed, and  showed  some  disposition  to  inflame,  I 
directed  the  aqua  aceti  lithargyrita  to  be  applied 
to  them.  On  the  following  day  some  matter 
flowed  through  the  orifice;  the  patient  supposed, 
if  collected,  it  might  be  a  table  spoonful.  Nearly 
the  same  quantity  continued  to  discharge  for 
about  a  fortnight,  and  afterwards  it  gradually 
diminished,  and  the  wound  healed.  She  was  not 
affected  by  fever  in  consequence  of  this  last  open- 
ing, and  seemed  to  suffer  very  little  inconvenience 
with  respect  to  her  health.  She,  however,  com- 
plained much  of  pains  resembling  those  of  the 
rheumatism,  which  affected  principally  her  hips, 
though  sometimes  they  attacked  her  loins.  For 
these  pains  she  was  placed  under  the  care  of  the 
Physician,  and  as  her  constitution  was  languid, 
she  was  recommended  to  continue  the  medicines 
prescribed  for  her  as  an  out-patient." 


28  On  Lumbar  Abscess. 

Although  the  practice  in  this  case  was  con- 
trary to  the  original  intention,  yet  it  appears  to 
me  fortunate,  for  if  the  matter  had  been  com- 
pletely discharged,  I  doubt  if  the  patient  would 
have  so  easily  got  through  the  .disease.  The 
quantity  of  matter  remaining  after  the  partial 
evacuation  afforded  a  sufficient  support  to  the 
surrounding  parts  to  prevent  excess  of  debility 
from  depletion;  the  vessels,  therefore,  retained 
their  tone,  and  the  matter  secreted  from  them 
assumed  its  healthy  appearance.  As  no  unusual 
excitability  was  induced,  little  or  no  inflammation 
could  be  excited;  for  as  soon  as  the  pressure  of 
matter  was  withdrawn,  the  cellular  substance 
reacted  and  occupied  the  space. 


THE  END. 


COLUMBIA  UNIVERSITY 

This  bqok  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

C28I6381MS0 

(A 

LIBRARIE 

80 

=CD 
=00 

=o 

I  IT) 


B27 


